Personal Trainer Client Intake Form

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

FemaleMale
Weight
kg
Phone Number

Area CodePhone Number
Email
example@example.com
What is your goal? What timescale do you have to achieve this?
What statement best describes you?
What have you tried in the past? Diets, training, programs, coaches, Gyms etc!
How does your current diet look like?

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Do you smoke?

YesNo
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
How often do you want to do personal training a week?

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Which of the following statements fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
Should be Empty:

Your Information